The rhythm of pressure: Circadian disruption and chronotherapy

Disruption of circadian blood pressure (BP) rhythm is a key pathophysiological feature and an important marker of cardiovascular risk. Ambulatory BP monitoring, the gold standard for assessing BP circadian patterns, has revealed that non-dipper and reverse-dipper phenotypes are strong independent predictors of coronary artery disease, atrial fibrillation, heart failure, and all-cause mortality. Notably, even when daytime BP is adequately controlled, abnormal circadian BP profiles impose sustained cardiovascular stress, accelerating target organ damage, including left ventricular hypertrophy, atherosclerosis, atrial remodeling, and renal impairment. Accordingly, assessment of BP circadian rhythm has become an essential component of contemporary hypertension management. It not only helps to accurately identify high-risk patients who might be missed by conventional office BP measurements but also provides a knowledge basis for optimizing antihypertensive medication strategies according to individual rhythm classification to restore physiological nighttime BP pattern. We summarize evidence from clinical trials evaluating chronotherapy for BP control and discuss current guideline recommendations worldwide. Despite growing interest, important knowledge gaps remain, including incomplete understanding of underlying mechanisms and substantial interindividual variability in treatment response, underscoring the need for precision, rhythm-guided therapeutic approaches supported by robust outcome-based evidence.